Determine whether you’ll be ready for the new coding system with this sample note.
Although you’re probably a professional at coding your pediatric documentation at this point using ICD-9 codes, chances are high that you haven’t yet coded a note using only ICD-10 codes. Test yourself using this documentation example to determine whether you can select the right diagnosis codes, which will be required as of Oct. 1. Determine which ICD-10 codes you would report, then read on for the answers.
Scenario: An eight-year-old established patient presents for a well child visit. While there, the patient’s mother says that the child has recently needed to use his asthma inhaler twice a week, which has limited his activities of daily living to a slight extent, including his need to sit on the bleachers during his physical education class. Although the patient has had mild persistent asthma for a while, this is the first exacerbation that the parent has reported. Which ICD-10 codes should you report for this visit?
Question: How should I report prostate cyst aspiration and prostate cystogram? How do we report for the injection of contrast into the prostatic cyst?
Want your audit to be over quickly? Hand over the records.
If you’ve ever wondered what gives auditors the biggest headache, you might be surprised at the answer. Although your first instinct might be that auditors find messy records or illegible documentation, the reality is that they frequently deal with providers who can’t produce any documentation at all.
Find What the Auditor Is Missing
Scrutinize the op report to determine whether the physician used a tissue scaffolding device.
If your orthopedic surgeon documents using a tissue scaffold such as the GraftJacket, Conexa or another similar implant during rotator cuff repairs, you may find yourself in a coding quagmire — CPT® does not include a code for the tissue scaffolding procedure, but the physician thinks that the extra work is worth more than a standard rotator cuff repair.
You can code RCRs with tissue scaffolding like a pro, even if you’re a first-timer. Read our experts’ advice, and find out just how to get your coding on the straight and narrow.
Recognize Tissue Scaffolding in the Documentation
The first step in determining whether your surgeon performed a tissue scaffolding procedure is to examine the op note. For example, the physician might refer to an “acellular dermal matrix,” “GraftJacket,” “GJA,” “Restore implant,” or “tissue scaffold” when explaining the procedure he performed.
Hint: In many cases, an additional digit will specify which eye is infected.
When ICD-9 becomes ICD-10 in 2015, you’ll have to be prepared for changes across the board when it comes to diagnosis coding. Often, you’ll have more options that may require tweaking the way you document services and a coder reports it. Check out the following examples of how ICD-10 will change your coding options.
Get ready now: The deadline for using ICD-10 is Oct. 1, 2015.
Nail Down These Upcoming Eye Infection Coding Changes
Conjunctivitis is an eye infection that can affect patients of all ages, and your practice is probably familiar with the signs and symptoms of this condition. But, like all other conditions, conjunctivitis will fall under new codes under ICD-10.
Question: I saw your article on new 2015 codes 52441 and 52442. Is there a specific code for a permanent intra-urethral urethral stent or prostatic stent? Will I be able to use 52441 and 52442 for those stents?
New Jersey Subscriber
Hint: Documenting HPI is the job of the doctor or NPP.
Your nurse might be quite adept at recording your documentation—but if she documents too much, your notes might not be applicable to your coding choices. That’s the word from a new E/M Tip that Part B MAC Palmetto GBA issued last week, reminding doctors what ancillary staff members can document in your Medicare records.
“Ancillay staff may only document the Review of Systems (ROS), Past, Family, and Social History (PFSH) and Vital Signs,” the latest tip, published Sept. 23, indicates.
As for the history of present illness, leave that to the physician or NPP, Palmetto says. “Only the physician or NPP that is conducting the E/M service can perform the history of present illness (HPI). This is considered physician work and not relegated to ancillary staff. The exam and medical decision making are also considered physician work and not relegated to ancillary staff.”
Deadlines rush your lab clients to EHR, too.
With more than enough pay cuts to go around, nearly anything your lab can do to hold on to earnings is a step worth taking.
Read on to make sure you know what’s happening with certain Medicare program options, such as the Physician Quality Reporting System (PQRS), that could impact your bottom line.
Look for PQRS Penalty Notifications
The 2013 PQRS incentive program feedback reports are currently available if you’re interested in reviewing yours, said CMS’s Christina Phillips during a recent Open Door Forum call. “There are two different types of reports you can access—one is the NPI identifier level report,
The October 2014 CPT® Assistant is jam-packed with updates for the newly-created Care Management Services in the E/M section. Get the inside scoop on services that care management includes and what’s involved when calculating total time. Evaluate provider requirements for care management and additional E/M services you can report with care management codes.
Nail down correct codes for endovascular treatment for lower extremity venous incompetency and positive airway pressure (PAP) therapy. Sharpen your skills for coding trigger point injections using dry needling technique, and much more. Put SuperCoder.com’s Code Connect code and keyword search to good use to deepen your understanding of these topics:
- Care management services: 90951-90970, 98960-98962, 98966-98968, 98969, 99071, 99078, 99080, 99090, 99091, 99201-99215, 99324-99328, 99334-99337, 99339-99340, 99341-99345, 99347-99350, 99358-99359, 99363-99364, 99366, 99368, 99374-99380, 99441- 99443, 99444, 99487-99490, 99495-99496, 99605-99607
- Endovascular treatment for lower extremity venous incompetency: 29581, 29582, 36000-36005, 36410, 36425, 36478, 36479, 37241-37244, 36468-36479, 37765-37766, 37799, 75894, 75898, 76000, 76001, 76937, 76942, 76998, 77022, 93970, 93971
- ICD-10: Table of Drugs and Chemicals
- Positive pressure therapy: 94660, 94002-94005, 94660, 95811, 95783, 99201- 99499
- Trigger point injections: 20550-20553, 20999
You’ll also find the customary FAQ section in the latest CPT® Assistant to help you resolve your toughest coding cases. To find the help you need, search for these codes and keywords on Code Connect:
Not sure whether to use the ‘insufficiency’ or ‘other’ code for incompetence NOS? Here’s the answer.
ICD-10 is ousting the simplicity of a single code for nonrheumatic mitral valve disorders. Check out the five new options you’ll need to know.
424.0, Mitral valve disorders